TREATMENT.

This might all be summed up in a few words. Keep your patient quiet; reduce a high temperature by sponging with cold or tepid water, as preferred by the patient. Feed your patient nourishing liquid, and semi-solid food. If you find that any certain food does not digest, as I did in one of my own children who was fed on a soft boiled egg, leave it off. Examine every discharge from the bowels, and you will always be able to know how your nutrition is being appropriated. I prefer the free use of butter milk to any other method of feeding. Soups, toast, rice, gelatine, oat-meal and other similar foods will furnish a sufficient variety for any patient. You ask, is no medicine given? Yes. As a rule I give carb. guaiacol in a solution of salicylate of soda, about as follows:

This tends to lessen the temperature, disinfects the alimentary canal and keeps the emunctories active.

In addition, after the first week I add as a tonic:

R Tr. Iodine.

Liq. Potass, Arsenit_.

Aquae.

M. et. ft. Sol.

of each, 1 dram.

q. s., 4 ounces.

Sig:-Shake. Teaspoonful every four hours, alternated with above mixture.

Some indications may arise that call for some special medication, but these must be met as they would be in other diseases. In the latter part of the disease, when sweating becomes profuse, the use of the fluid extract of belladonna may be indicated. Should there be much nervous debility, as is seen in a few cases, strychnia should be given. As a rule these cases could all be managed without medicine, as nothing appears to shorten the duration. A condition of euphory seems to result from the medication as outlined above.

DISCUSSION.

Dr. Hail: Being located in the Delta of the Mississippi for many years, I have seen hundreds of cases of this fever. It has been my experience that it goes from four to six days before any attention is given to it. People get into the habit of taking a dose of calomel and waiting for that to act, and if it does not act and if there is fever for a few days, then they will call the doctor. I have always found my cases of continued fever of this class. My belief is that the system becomes so poisoned with toxins that it is purely a toxic fever. I remember one case that ran its course in one hundred and two days and the temperature never went over one hundred. Another thing, in these cases is that the pulse is always lowered, and, as the doctor says, we never have any gurgling upon pressure over the abdomen. If you give them quinine for thirty-six to sixty hours, you will produce delirium. Just as soon as I discover that a case is liable to be a continued one, I cut off the quinine. I then give elixir of pepsin, feeding them a nourishing diet which will, at the same time, stimulate them and keep them going.

Dr. Boyd: I have enjoyed this paper very much but I cannot agree with the essayist in everything he says. Continued research has not solved the problem. This disease frequently gives the malarial parasite in the beginning, and the clinical picture is that of typhoid fever. It was first thought that when they did not give the Widal reaction, that they were not typhoid, and when there was nothing in the way of plasmodial reaction, they were not malarial. The great bone of contention is the fact that it does not always give the typical reaction, and because of this it is said that it cannot be typhoid. The recent observations in this country and abroad indicate that this last link in the chain has been found. If these cases be tested for the para-typhoid bacillus, they will, in practically every case, give the typical reaction, showing that there is an infection of the para-typhoid bacillus. About twenty per cent. of these cases, are cases of para-typhoid infection, while the remaining are typhoid. We are told that these bacilli are much like typhoid bacilli. The picture is practically one and the same. We know from our experience, that the clinical pictures are identical, with the possible exception that the typhoid is the

more virulent. I challenge any man to make a definite diagnosis without the miscroscope. If these fail to give the reaction and when tested for para-typhoid give the agglutination, then I see no use in attempting to give a new name to these cases any more than giving a new name to streptococcic anaemia. It is confusing and misleading, and we have no new fever. For all practical purposes it is typhoid.

Dr. Happel (in closing). The last speaker reminds me of an incident in my boyhood. It had been said about an old barn that it was full of rats. Most people present had consented that there were rats in the barn, but one man declared he had never seen a rat there in his life. It was then decided to pull down the barn just to show him that there were rats in it. When they pulled it down, he still said that he could see none and when they examined him, they found that he had had his eyes shut all the time. This speaker says that a large percentage of his cases present the characteristics of typhoid fever. I have examined a large number of these cases and have ir no case found indications of typhoid fever. We make a diagnosis of typhoid fever, especially when we have symptoms to indicate it. The tympanitic abdomen, coated tongue and Widal test-then you know you have typhoid fever, but when you do not get any of these responses, I should consider carefully before calling it typhoid fever. The patient says he can work, that he is not sick-I have had them beg to go to work. They have a soft abdomen and soft tongue. He says his cases present diarrhoea; in no case in this disease do we find diarrhoea unless from bad feeding. If he will feed his cases that he recognizes as typhoid fever with sardines, he will have a burial. One man made a memorandum in his book that dried herrings were a very good diet for the Frenchman, but sure death for a Dutchman. You can give to these people such a diet as any person world ordinarily be able to take.

One thing I omitted to say in reference to those cases of the fever in which the temperature does not rise above 102F. In such cases, we can never predict when it is going to end. Where the case begins very rapidly, you can safely predict rot more than four weeks, but when you have a case that comes en slowly and has a slight fever, it will drag along from five to six, eight or ten months.

THE GENERAL PRACTITIONER IN OBSTETRICS.

BY BENJAMIN BRITT SIMS. M. D., Talladega.

Junior Counsellor of the Medical Association of the State of Alabama.

The subject to which I invite your attention for discussion is cld, older even than medicine itself; it has been hashed and rehashed, discussed and re-discussed from every point of the medical compass, and I am free to admit that I have nothing new to which I would call your attention today. Then, you, no doubt, are asking: Why take our time with such a hackneyed subject? Because I see that we, as older men, have made blunders and errors which our forefathers made that cost many mothers and infants their lives; and because I see that the younger men of today are making the same mistakes which we and our predecessors have cause to regret,

And again, there are other reasons, which I will mention later, that make me believe that a discussion of this subject is needful. In Alabama, and in the other Southern states, the general practitioner has charge of the great majority of cases of obstetrics, and I will make the assertion here that we get less pay for it according to time and skill required than in any other branch of medicine.

I wish first, to call attention to some mistakes I have made in attending breech presentations, and I notice that identically the same errors are being made today by some of the younger

men.

For example, we are called to a primipara in labor and after sterilizing our hands, genital organs of the patient, etc., we make a vaginal examination and can reach no part of the child. We are not very well trained in determining the position by external manipulations, so we fold our hands and wait for results; the pains are very good but there seems to be no progress. We get impatient and want to leave for a while to make other calls; but the scared husband and the patient's over anxious father and mother who are momentarily expecting to be grandpa and grandma for the first time, will not listen to our leaving for one minute. And so again we fold our arms and begin to

wait for results. The pains get harder, the patient's complaints get louder; the husband, who has never witnessed anything of this kind, thinks his wife is having a fearfully hard time. And the aforesaid father and mother, who have forgotten more than they ever knew about having babies, concludes that it is time for the doctor to do something, and proceeds to inform us that poor "Mary" is having an awful time, and exclaim, "Doctor, can't you do something to help her?" We make another vaginal examination, and find a rather indescribable tumor that we judge to be the breech. We inform the father and mother that Mary is in no danger and that it is best not to interfere. Thus far we have done all right and served our patient well, but as the pains increase in severity, and the groans of the patient become more piercing, that husband becomes more restless and frightened, the father and mother continue to be oblivious to the fact that it is necessary to have pain to give birth to a child, and we, at their earnest solicitation, lose our heads, forget our teaching, and consent to make that fatal mistake of interfering with a normal breech presentation in a primipara with tense unrelaxed tissues.

Probably we will now anesthetize the patient and make a futile effort to apply forceps to the breech not yet engaged in the brim. Failing in this we become desperate, introduce our hand and bring down a foot, make traction, and after much effort deliver the body of the child. But we have by traction extended the head, the chin is no longer flexed upon the chest, but is extended, the occiput lying on the spine. Now this being a primipara, the tissues are taut, we have not given them time to dilate and become lax, and, do what we will or may, that child will suffocate before we can deliver the head.

The moral is to fix our charges sufficiently high that we can afford to sit and wait, explain to those anxious relatives why it is best to wait, and we are masters of the situation.

Of course, the foregoing case is understood to be an uncomplicated breech. Certainly if there were symptoms of threatened eclampsia interference for the sake of the mother is entirely proper. But merely to save time and please relatives who do not understand the situation, it is never justifiable to interfere in such cases.

And further, not only is the child sacrificed but very often there is a grave laceration of the perineum, thereby increasing the danger of infection, and, many times, requiring a later or